Critical analysis of the pediatric end‐stage liver disease scoring system: A single center experience

Abstract

The Pediatric End-Stage Liver Disease (PELD) scoring system is a new nationally utilized formula developed to provide a continuous numerical assessment of the risk of death in order to allocate livers to children for transplantation. A retrospective review of the clinical course of children undergoing liver transplantation at the Mount Sinai Medical Center was performed in order to assess the effectiveness of this scoring system in the first 24 months of its utilization. Forty-eight patients underwent liver transplantation with overall patient and graft survival rates of 98% and 96%, respectively. In 23 cases the PELD scoring system determined waiting time for transplantation. Of these 23 patients, 7 moved to the intensive care unit (ICU). Only 2 of 23 patients underwent transplantation with their actual PELD score. The rest required petition for exception (17) or status 1 listing (4). Significant morbidity occurred while awaiting transplantation: failure to thrive (78%), ascites (73%), hemorrhage (49%), infectious complications (39%), encephalopathy (30%), peritonitis (17%), pathologic bone fractures (13%), and hepatopulmonary syndrome (9%). In patients with PELD scores granted by exception the average score that did not yield a liver offer was 38 with an average waiting time of 55 days. At the time of transplantation actual PELD score averaged 22, while the petitioned score was 40. Based upon our center's initial experience, the current PELD scoring system is not adequate. Actual PELD scores did not lead to timely allocation of livers to children. It appears that this scoring system underestimates the nearterm risk of death. Urgent reassessment is required to prevent potential morbidity and mortality in children. In conclusion the United Network for Organ Sharing policy that permits granting of exceptions has circumvented these problems with the PELD scoring system. (Liver Transpl 2005;11:788-795.) O rgan transplantation is a life-saving therapy for many individuals with acute and chronic diseases. The relative success of this therapeutic approach and expanding indications for transplantation coupled with persistent lack of long-term efficacy of other treatments for end-stage organ failure has led to continued relative shortages of organs for transplantation. In light of these shortages, a number of systems have been developed to ration available organs to individuals in need according to ethical, medical, and social criteria. Each system that has been developed strives to optimize organ allocation, with maximal benefit and minimal morbidity and mortality to those who await available organs. Several iterations of allocations systems have evolved. At the outset, each system is designed to be objective and attempts to avoid subject bias. Individual medical centers that participate in these allocation programs are faced with competing demands. One demand from society as a whole is to maintain a "fair" system for all individuals in need of a scarce organ. A competing demand, from individual transplant candidates, ...

Pediatric Transplantation in the United States, 1996–2005

“…If we wish to change this high rate, several potential contributing factors will need to be examined to determine causes and possible solutions: (1) etiology of liver failure; (2) timing of referral for transplantation; Concerns have been raised about the ability of the PELD score to reliably prioritize children for liver transplantation (20,21). Also, the correlation with MELD scores may be imprecise, making it difficult for children to compete with adult candidates for organs (20,21). Both of these factors have been felt to disadvantage certain candidates in terms of timely access to a liver allograft.…”

“…A number of publications have voiced concern that the present allocation system is not serving children well (20,21,23), but pediatric pretransplant death rates have not risen with the introduction of MELD/PELD nor with any of the subsequent policy modifications. It is possible that the candidates who die on the waiting list may have changed in terms of the severity of diagnosis or geographical distribution from those who died waiting during the pre-MELD era.…”

“…There was no interaction between PELD and the liver/intestine wait-listed candidates, indicating a consistent difference in mortality across PELD scores. The mortality risk among pediatric liver/intestine candidates was 5.5 times higher than that among pediatric liver candidates, which equates to 23 PELD points (95% CI [18][19][20][21][22][23][24][25][26][27][28]. For patients with a MELD score, the mortality rate difference was smaller, and a clear interaction could be seen between MELD and liver/intestine candidates.…”

Pediatric Liver Transplantation

“…Children with a PELD greater than 12 ( n = 47) had a higher rate of post-LT mortality and retransplantation than those with a PELD of 10 or less. The authors suggested that a PELD score approaching 10 should trigger discussion of LT. PELD is the only scoring system currently used in children and although helpful in advanced liver dysfunction; it is of limited value in the very young (under 1 year of age) and in older recipients, particularly with complications such as recurrent cholangitis, severe portal hypertension, pulmonary hypertension, and hepatopulmonary syndrome [25][26][27][28][29]. Because of these limitations, PELD use has been largely restricted to North America.…”

Pediatric Liver Transplantation: A Surgical Perspective and New Concepts

“…However, many publications have shown that the PELD system is not an accurate reflection of the degree of illness for most of the children waiting for LT [1,2]. Furthermore, disparities in the current organ allocation system in the USA have been proven [3••].…”